Every day I experience life in the world of healthcare IT, supporting 3000 doctors, 18000 faculty, and 3 million patients. In this blog I record my experiences with infrastructure, applications, policies, management, and governance as well as muse on such topics such as reducing our carbon footprint, standardizing data in healthcare, and living life to its fullest.

Wednesday, September 28, 2011

The September HIT Standards Committee Meeting

Today was a big day - the end of Standards Summer Camp. We presented the HIT Standards Committee work of the past 6 months and then attended a celebratory reception at the White House.

Judy Sparrow, the ONC "national coordinator" who orchestrated all our HITSC meetings, announced her retirement last month. Jon Perlin and I presented her with a silver bowl, engraved with the words "The Standard Bearer". Thanks for all you've done, Judy.

As we discussed our Summer Camp work during the meeting, we were guided by a few basic principles:

While it might not be perfect, does it represent the best we have at this point in history?
Does it point us in the right direction?
Is it the next step in an incremental approach to refining the standards and implementation guides?
Does it support our policy objectives?
Can we update it as needed going forward through the SDO community?

The Metadata Analysis Power Team lea by Stan Huff completed the standards for patient identification, provenance (which organization generated the data), and security flags. Simple XML constructs from CDA R2 and standard X.509 certificates were chosen for these requirements.

The Patient Matching Power Team led by Marc Overhage completed its analysis of best practices for patient matching, noting the types of demographics that should be captured in systems to optimize the sensitivity and specificity of patient matching applications.

The Surveillance Implementation Guide Power Team led by Chris Chute chose one implementation guide for each of the public health transactions - surveillance, reportable lab, and immunizations. We had a spirited discussion about the optional fields in the implementation guides and made it clear that we want the core elements to be the certification criteria. We do not want each state public health department to mandate different "optional" fields. Our transmittal letter will note that EHRs that send the core set should meet the certification criteria. Public health departments should accept this core set. Optional fields are just that - optional items for future reporting needs.

Farzad Mostashari, National Coordinator, framed the important discussion of transport standards by noting that we must move forward, boldly specifying what is good enough. If we specify nothing, the silos of data we have today in hospitals, clinician offices, pharmacies, and labs will persist. There's a sense of urgency to act.

The NwHIN Power Team led by Dixie Baker presented its thoughtful analysis of the 10 standards guides included in NwHIN Exchange and the 2 standards guides included in NwHIN Direct. This analysis was not a comparison of the two, but was an objective look at the suitability of each standards guide for its intended purpose to support aspects of transport functionality at a national scale. The team did not discuss their suitability for use at the local, state, or regional scale. The team did not declare "push or "pull" as a superior architecture. Their thoughtful analysis led to a very robust discussion. I'd summarize it as:

*Direct is low risk for the purpose intended, pushing data from point A to point B using SMTP/SMIME with an optional XDR (SOAP) connector. Additional work needs to be done on certificate discovery, but that will use DNS and LDAP, two well adopted technologies.

*Exchange needs additional work to ensure it scales at a national level for pull and push transactions. The S&I Framework teams are working on modular specifications that should enable a subset of Exchange components to be used, simplifying implementation and support. The Standards Committee will seek additional testimony from Exchange implementers to learn more about their experience.

*It's worthwhile to think about additional transport standards that do not yet have well specified implementation guides, such as a combination of REST, oAuth and TLS - something that Facebook, Amazon, or Google would use to create a highly scalable transport architecture.

The ePrescribing of Discharge Meds Power Team led by Jamie Ferguson presented the use of HL7 2.2-2.51 transactions to support hospital information system workflows in a manner that is compatible with Medicare Part D. We clarified that newer versions of HL7 2.x which are backward compatible should also be allowed.

The Clinical Quality Workgroup and Vocabulary Task Force led by Jamie Ferguson presented their transition plans for vocabularies, identifying the cross maps between vocabularies that need to be created and supported as we evolve from our current use of vocabularies to a future state in which there is one structured vocabulary per domain of medicine (problems, medications, labs, allergies etc).

Transitions of Care - Doug described a brilliant approach that incorporates simple XML, such as has been used in the CCR, with the expandability of the CCD. He calls this next evolution of clinical summaries "Consolidated CDA templates". It's likely that the clinical summary certification criteria will evolve to a single XML format that is easy to use, fast to implement, expandable, based on a reference model, and human readable. Well done!

Reportable Labs - In the past, standards harmonizers struggled to balance simple, easy to implement lab specifications such as ELINCS with the comprehensive and full featured lab specifications from HITSP. The S&I group created a foundation based on ELINCS that is expandable to include all the features of the HITSP specifications using a single HL7 2.51 implementation guide. Amazing work.

Provider Directories - The S&I Framework team had the courage to admit that directory standards are still evolving and need more testing/piloting before selection. DNS/LDAP approaches are likely to work well for certificate discovery. Other aspects of directories such as provider routing addresses and electronic service capabilities may be stored in web pages (microdata), LDAP (HPD), or X12 274 directory structures.

Doug also described new works in progress - Query Health for distributed data mining, Data Segmentation to manage disclosures of protected health information, and Electronic Submission of Medical Documentation for transmission to Medicare review contractors.

Truly an inspiring meeting - the most work we've ever done in a single day.

The delivery of Meaningful Use Stage 2 Standards and Certification criteria was recognized at a White House celebration by Aneesh Chopra, Chief Technology Officer and numerous members of the Obama administration senior staff. Thanks so much to Aneesh and others for celebrating our work.

As I told the Standards Committee today, I am honored to serve with this team, the hardest working Federal Advisory Committee in government. A milestone day for the country.

2 comments:

I always look forward to your summaries of these meetings, you and Jonathan had a huge task to control this meeting.

I think you have underreported the vigorous discussion around the assessment on NwHIN-Exchange. There was strong positive support voiced by many members of the committee. Jamie Furgenson (Kaiser), Chris Chute (Mayo), and Tim Cronwall (VA). All pointing out that they are going forward with Exchange, and that it is not hard. They use available tools such as CONNECT and OHT. Note that Stan Huff(Inter-Mountain) and James Walker (Geisenger) could have said the same, but I think they simply were not present. This is 5 members of the committee that are committed to using Exchange; clear support.

The only detractors I have heard are the immaturity of ONE specification that uses XACML. This one specification is not a formal specification. It is a first draft. It is not implemented. It is not critical. It should not have been included in the assessment.

The discussion about layers during the power team meeting was seen as a positive. The use of layers is a design principle used to deal with complex problems. Yet during the HITSC meeting, layers were presented as a bad thing.

Direct has few layers, because they have pushed the hard problems into policy/process - meaning humans must handle the hard things. Exchange has provided technical solutions, and this is somehow seen as bad.

Please see many positive and constructive comments placed on twitter by a large community including myself http://twitter.com/#!/search/realtime/%23HITSC

It is great to see a recommendation coming from Dixie Baker regarding the necessity of creating a REST/OAuth/TLS exchange pattern. For this, I would like to bring your attention to hData, which has been pioneering the application of common web technologies and architectures (including REST & OAuth) to the health IT domain.

The two component hData specifications (HRF and REST Binding) and recently passed HL7 DSTU ballot/OMG DTC vote, and are currently available as peer-reviewed draft standards here and here.

Shameless plug: Note that these specs have not been finalized, and that - right now - would be a great time to engage in a discussion. In fact, any help is always appreciated.